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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline

January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e28

CLINICAL STATEMENTS AND GUIDELINES

participation in treatment decisions.7 The use of online modules, decision aids, or videos about treatment options can help patients better understand the risks and benefits of various therapies. Patients are interested in how a recommended treatment might impact their prognosis and quality of life.8 In the treatment decisionmaking process, the patient’s best interest should be placed first, and the active participation of the patient and significant others should be engaged. The contributions of social determinants of health to CVD are poorly understood.9,10 but may impact a patient’s decision with regard to treatments. In high-income countries, 4 socioeconomic status metrics have been associated with CVD: income level, educational attainment, employment status, and environmental factors.11-13

Recommendation-Specific Supportive Text

1.	 Shared decision-making is vital to patient-centered care. Shared decision-making improves patients’ understanding of treatment options, increases realistic expectations of benefits and harms, stimulates engagement in decision-making, and improves concordance between patients’ values and treatment choices.14-17 Factors complicating effective shared decision-making include low health literacy, adverse social determinants of health, cultural beliefs, language barriers, advanced age, and complex comorbidities. Health literacy is associated with socioeconomic position, English proficiency, and the development of general literacy.18 Incorporating a patient’s preferences into the decision-making process improves the patient’s well-being through better treatment adherence and higher satisfaction with health outcomes.5,19,20 A patient’s right to decline recommended treatments must be respected and should be acknowledged in a written document after the patient has received sufficient information from the Heart Team.8 2.	 Patients cannot engage in shared decisionmaking until they know the potential benefits and risks of all treatment options. Clinicians must provide evidence-based estimates of risks, benefits, and costs of therapeutic options.8,21,22 Procedure-related and long-term risks and benefits, such as survival, quality of life, and the need for late reintervention, should be included in such discussions (Table 3).8 Patients should also be educated about the need for continued medical therapy with or without revascularization, as well as lifestyle modification and other secondary prevention strategies.21,23 In some situations, in which the optimal treatment strategy is uncertain, it may be appropriate to defer revascularization to allow time for consultation and discussion. The clinician must act in the patient’s best interest and convey the risks and benefits of all revascularization treatment options, consult with additional specialists when appropriate, and allow the patient to consult family.24,25 Challenges exist

Table 3.  Ideal Components of the Shared Decision-Making and Informed Consent Process Patient-Centered Care Assess a patient’s ability to understand complex health information Seek support of family/others Elicit and respect cultural, racial, ethnic, or religious preferences and values Evaluate social determinants of health (education, income, access to health care) Improve telephone/telemedicine access Discuss treatment alternatives and how each affects the patient’s quality of life Shared Decision-Making Encourage questions and explain the patient’s role in the decision-making partnership Clearly and accurately communicate the potential risks and benefits of a particular procedure and alternative treatments Ensure that patients have a key role in deciding what revascularization approach is appropriate Use shared decision aids: Alphabetical List of Decision Aids by Health Topic, Ottawa Hospital Re-

search Institute (https://decisionaid.ohri.ca/implement.html)27 SHARE Approach Curriculum Tools, Agency for Health care Research

and Quality (https://www.ahrq.gov/health-literacy/curriculum-tools/shareddecisionmaking/tools/tool-1/index.html)28 Spend sufficient time to engage in shared decision-making; allow for a second opinion Work with a chaplain, social worker, or other team members to facilitate shared decision-making Encourage patients to share their fears, stress, or other emotions, and address appropriately Negotiate decision in partnership with the patient and family members Respect patient’s autonomy to decline recommended treatment Consent Procedures Use plain language, avoiding jargon, and adopt the patient’s words; integrate pictures to teach Document teach-back of patient’s knowledge and understanding Conduct conversations with a trained interpreter, as needed Provide patient-specific short- and long-term risks, benefits, and alternative treatments Provide unbiased, evidence-based, reliable, accessible, and relevant information to patient Discuss specific risks and benefits with regard to survival, relief of angina, quality of life, and potential additional intervention, as well as uncertainties associated with different treatment strategies Provide patient time to reflect on the trade-offs imposed by the outcome estimates Provide information on the level of operator expertise, volume of the facility, and local results in the performance of coronary revascularization options Clearly inform of the need for continued medical therapy and lifestyle modifications

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